What You Need to Know About Thyroidectomy

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Surgery on the thyroid gland, called a thyroidectomy, involves removal of some or all of your thyroid. It's performed for a variety of reasons and the amount that's removed depends on why you need the surgery. A thyroidectomy is traditionally an inpatient surgery that involves an overnight stay, though many practices perform outpatient surgery as well. Knowing what to expect can help you prepare for your procedure, its possible complications, and your recovery.

Purpose

Thyroid surgery is performed in a number of circumstances, including:

  • To rule out or treat thyroid cancer
  • To remove small growths on your thyroid (cysts or nodules)
  • When an enlarged thyroid (goiter) or multiple nodules swell and cause cosmetic, breathing, or swallowing problems
  • In pregnant women when hyperthyroidism (overactive thyroid) is not controllable with antithyroid drugs and requires immediate treatment
  • When other forms of treatment for hyperthyroidism, i.e. antithyroid drugs or radioactive iodine, have not been effective
  • When you don't want to have radioactive iodine or you can't use antithyroid medications
  • In children, if the practitioner or parent wishes to avoid radioactive iodine

Types

There are two main types of thyroid surgery: total and partial thyroidectomy.

Total Thyroidectomy

A total thyroidectomy removes the entire thyroid and is typically used for thyroid cancer, especially aggressive cancers, such as medullary or anaplastic thyroid cancer. It's used for large goiters with multiple nodules, Graves' disease, and hyperthyroidism as well.

Partial/Subtotal Thyroidectomy

In a partial thyroidectomy, surgeons typically perform a bilateral subtotal thyroidectomy, which leaves from 1 to 2 grams on each side/lobe of the thyroid. A Dunhill procedure is also popular, in which there's a total lobectomy on one side and a subtotal or near-total on the other, leaving 1 to 2 grams of thyroid tissue remaining. Both the bilateral subtotal thyroidectomy and the Dunhill procedure are also often used for Graves' disease.

Partial vs. Total

The issue of a partial vs. total thyroidectomy can be controversial, but it really depends on the reason you're having the surgery in the first place. For instance, if you have a large tumor, a total thyroidectomy will likely be recommended, whereas if you have a small, non-aggressive tumor that's contained to one side, you can probably just have that side removed.

Some practitioners prefer to perform a partial thyroidectomy whenever possible, believing that they will leave behind enough thyroid tissue to prevent hypothyroidism (underactive thyroid). Having a total thyroidectomy always eventually results in hypothyroidism, since your body no longer has a way to make thyroid hormones.

But though the risk of developing hypothyroidism after partial thyroidectomy varies from study to study and depends on different factors, the chance of this happening may only be around a 20 percent.

For patients with Graves' disease, both total and partial thyroidectomies are utilized. A 2015 Cochrane study found that total thyroidectomy is more effective than both the bilateral subtotal thyroidectomy or the Dunhill procedure when it comes to preventing hyperthyroidism from coming back. Neither one had an effect on the regression of the eye disease that often accompanies Graves' disease.

The bottom line is that deciding how much of your thyroid to remove can be a complex decision when there's not an obvious recommendation. Talk over the pros and cons of each type of thyroidectomy with your surgeon.

Choosing a Surgeon

Complications are more likely with surgeons who have less experience performing thyroid surgery, so make sure that your surgeon has extensive experience in thyroid surgery and that he or she does these surgeries regularly. You may want to ask your primary care doctor where he or she would personally go for a thyroidectomy.

How to Find a Top Thyroid Surgeon

Inpatient vs. Outpatient Surgery

Depending on your condition, an overnight or two-night hospital stay may be planned, but outpatient thyroid surgery is becoming increasingly utilized. This may be a viable alternative for many patients, though it's still somewhat controversial.

Safety and Cost

A 2018 systematic review concluded that outpatient surgery may be just as safe as inpatient surgery, as long as patients are carefully screened using selection criteria such as that suggested in the American Thyroid Association's guidelines. These include:

  • You don't have any major coexisting health conditions
  • You're given education regarding the surgery and you understand it
  • There's a team approach regarding education and care
  • Your primary care doctor is available and agreeable to you having outpatient surgery
  • You'll have access to help from friends or family and be in a safe environment after the surgery
  • You're within a reasonable distance from a hospital and you have adequate means of communication, should an emergency arise

However, the risk for bleeding after surgery, known as a postoperative neck hematoma, is the number one argument against performing outpatient thyroidectomies. When this happens, it can cause a compromised airway or even death, which has led two international surgical bodies (The British Association of Endocrine and Thyroid Surgeons and The European Association Francophone De Chirurgie Endocrinienne) to recommend against outpatient thyroid surgery.

These postoperative neck hematomas are rare, but they're unpredictable. A 2017 review of 160 studies found that 70 percent of the patients who developed a hematoma after thyroidectomy (11 out of 14) did so between two and nine days after their operation, well after the time when they would have been discharged from the hospital in an inpatient setting. The remaining three developed a hematoma while they were still in the hospital after thyroidectomy. The study also noted that there were no factors to predict a postoperative hematoma.

The same 2017 review found that having outpatient surgery may save an average of $1301.

How you proceed should depend on your particular situation—the type and nature of the thyroid surgery you're having, your age, overall health, other risk factors, preferences, and the expertise of your thyroid surgeon. If you have a routine thyroid surgery and you're working with an experienced thyroid surgeon who recommends an outpatient surgery, it may be a safe and effective option for you.

What to Expect

In most cases, thyroid surgery isn't especially complicated and usually takes no more than a few hours. You will most likely be asked to check into the hospital the morning of your surgery.

General vs. Local Anesthesia

Thyroid surgery is usually performed with general anesthesia, but local anesthesia along with a sedative can be an alternative. Research shows that the outcomes are similar for both types of anesthesia.

Benefits of Local Anesthesia

  • Associated with shorter recovery time

  • Causes less post-surgery vomiting and nausea

  • May cost less

Benefits of General Anesthesia

  • No awareness of what's happening to you during the procedure

  • Enables you to stay completely still during surgery

  • Medical team has control over your airway to make sure that it's clear and you're breathing well

If you choose local, your doctor will typically give you numbing medication for the thyroid area, plus a mild sedative to help you stay calm. You'll be awake during the surgery and able to interact with your surgeon.

Because the majority of surgeons use general anesthesia for thyroidectomy, not many are trained to do it under local anesthesia. If you want to proceed with this option, be sure your surgeon has plenty of experience. Some experts suggest you look for a surgeon who has performed this procedure with local anesthesia at least 50 times.

Risks

As with any surgery, there are risks involved with having a thyroidectomy, including:

  • Infection
  • Bleeding
  • Postsurgical hematoma, which causes bleeding that can lead to respiratory distress
  • Nerve damage, which can result in temporary or permanent hoarseness
  • Damage to the parathyroid glands, located behind your thyroid, which can lead to temporary or permanent hypoparathyroidism and hypocalcemia, decreased levels of calcium and phosphorus in your blood
Hypoparathyroidism: Understanding Low Parathyroid Function

How to Prepare

Check with your surgeon about medications you're taking, and what you should and shouldn't take in the days prior to surgery.

Typically, your surgeon will ask that you refrain from eating or drinking after midnight the night before surgery.

You'll also need to make sure that you have someone to drive you home when your surgery is over and you've been discharged.

During the Procedure

There are three common surgical procedures that can be used for a thyroidectomy: traditional, endoscopic, and robotic.

Traditional Thyroidectomy

During a traditional thyroidectomy, the surgeon will cut a 3- to 5-inch incision across the base of your neck in front. The skin and muscle are pulled back to expose the thyroid gland. The incision is usually made so that it falls into the fold of the skin in your neck, making it less noticeable.

Blood supply to the gland is tied off and the parathyroid glands are identified so that they can be protected. The surgeon then separates the trachea from the thyroid and removes all or part of the gland.

Endoscopic Thyroidectomy

Some surgeons perform endoscopic thyroid surgery, which involves using a small magnifying camera that's inserted into a small incision in your neck to help guide the surgeon.

Carbon dioxide gas is pumped into your neck area to help make it easier to see and work on the gland. A second small incision is made, and a thin tube with a scalpel-like edge is inserted through that incision. This tube is the surgical tool that's used to remove the thyroid.

Because it involves two small scars of less than one inch, endoscopic thyroidectomy usually leaves less visible scarring and allows a quicker return to normal activity. Endoscopic surgery is not as commonly used as conventional surgery though, so you'll need to find a surgeon with experience doing these surgeries and explore whether it's appropriate for your particular condition.

Robotic Thyroidectomy

A robot assists with this procedure, which uses an incision that's either high on your neck, on the back of your neck, in your armpit, or in your chest. This type of surgery isn't commonly used.

Stitches

Most surgeons use dissolvable stitches, but you may want to ask your surgeon ahead of time which kind he or she plans to use because non-absorbable stitches actually tend to cause less scarring. If you have any history of allergic skin reactions to past stitches, you may also want to ask your doctor about using hypoallergenic suture material.

After Surgery

After the surgery, you'll usually remain under observation at the hospital for at least six hours while you wake up. If you're having outpatient surgery, you may be discharged after that point.

Before you are, your incision is usually covered with a clear, protective waterproof glue called collodium. This allows you to bathe or shower after the surgery.

If there's concern about bleeding or if your thyroid is very large and the surgery has left a large open space, a drain may be left in your wound to prevent fluid from accumulating. This is usually removed the morning after surgery.

You'll need to avoid excessive exertion for a few days to a few weeks. Your doctor will give you specific instructions.

Short-Term Side Effects

There are some common short-term side effects you may experience after thyroid surgery, including:

  • Pain when swallowing
  • Neck pain
  • Sore throat
  • Neck stiffness

Most patients also become temporarily hypothyroid after surgery and require thyroid hormone replacement therapy. If you've had a total thyroidectomy, you'll need to take this medication for the rest of your life since you no longer have a thyroid to produce these hormones. As mentioned earlier, even if you've only had part of your thyroid removed, you may still end up permanently needing thyroid hormone replacement therapy.

Potential Complications

While complications aren't common, a few can show up after thyroid surgery, including hypoparathyroidism and hypocalcemia and laryngeal nerve damage, discussed above. Signs of these can include:

  • Numbness and tingling around your lips, hands, and the bottom of your feet
  • Muscle cramps and spasms
  • Severe headaches
  • Anxiety
  • Depression
  • Hoarseness
  • Difficulty speaking loudly

Be sure to let your doctor know if you experience any symptoms of nerve or parathyroid damage.

A Word From Verywell

As you can see, depending on your situation, there may be several factors to consider when having a thyroidectomy. Understanding the pros and cons of each choice, as well as the risks involved, can help you, along with your surgeon, make an informed decision about how to proceed.

Post-Thyroidectomy Side Effects and Recovery
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